Evaluation of the normal craniocervical junction craniometry in 137 asymptomatic patients / Evaluación de la craneometría de la unión craneocervical normal en 137 pacientes asintomáticos

SUMMARY: To our best knowledge, most of the craniometric studies on the normal craniocervical junction (CCJ), are still poorly studied and based on measurements taken from plain radiographs. In this study, the authors conducted a craniometric evaluation of the CCJ in a population without known CCJ abnormalities. The purpose of the study was to assess the normal CCJ craniometry based on measures obtained from CT scans. The authors examined 137 consecutive CCJ CT scans obtained in patients evaluated at their hospital for treatment of non-CCJ conditions between 2018 and 2019. Twelve craniometrical dimensions were conducted, including the relation of the odontoid with the cranial base, the atlantodental interval (ADI), the clivus length, and the clivus-canal angle (CCA).

Hasta donde sabemos, aun son escasos y pocos los estudios craneométricos respecto a la unión craneocervical normal (UCCN) y estos se basan en mediciones tomadas de radiografías simples. En este estudio, realizamos una evaluación craneométrica de la UCCN en una población sin anomalías conocidas. El propósito del estudio fue evaluar la craneometría UCCN normal en función de las medidas obtenidas de las tomografías computarizadas. Los autores examinaron 137 tomografías computarizadas UCCN consecutivas obtenidas en pacientes evaluados en su hospital para el tratamiento de condiciones no UCCN entre los años 2018 y 2019. Se realizaron doce dimensiones craneométricas, incluida la relación del proceso odontoides con la base del cráneo, el intervalo atlantodental (ADI), la longitud del clivus y el ángulo clivus-canal (CCA).

A comparative study of the morphology of suboccipital cavernous sinus using magnetic resonance imaging and cast specimens / Un estudio comparativo de la morfología del seno cavernoso suboccipital utilizando imágenes de resonancia magnética y muestras de yeso

SUMMARY: A comparative study of the morphology of suboccipital cavernous sinus (SCS) using MRI and cast specimens was performed. The present retrospective study analysed the craniocervical magnetic resonance venography (MRV) imaging data of 61 patients. Three-dimensional reconstruction was performed using Mimics 19.0. The SCS left-right diameter(d1), distance from the midline (d2), supero-inferior diameter(d3), anteroposterior diameter (d4), distance from posterior diameter to skin (d5), and diameter of the SCS at different parts (d6-d8) were measured. Comparison between MRV images and cast specimens, the SCS, marginal sinus, anterior condylar vein, and vertebral artery venous plexus were symmetrical and could be bilaterally displayed, whereas the presence of extra condylar vein and posterior condylar vein exhibited different types. The adjacency between the SCS and its communicating vessels and changes in its communicating vessels corresponded well with the MRV images and cast specimens. Many types of the presence of left and right lateral condylar and posterior condylar veins were found in the cast specimens, which could be divided into the bilateral presence of posterior condylar and lateral condylar veins, unilateral presence of posterior condylar veins, and unilateral presence of lateral condylar vein. A total of 61 cases analysed using MRV images revealed the bilateral presence of posterior condylar and lateral condylar veins (77.1 %), the unilateral presence of posterior condylar vein (18.0 %), and the unilateral presence of lateral condylar vein (9.8 %), of which the bilateral presence of posterior condylar and lateral condylar veins accounted for the largest proportion. MRV images and cast specimens of the SCS showed its normal morphological structure and adjacency, thus providing accurate and complete Three-dimensional imaging anatomical data of the SCS and its communicating vascular structures. This study enriches the Chinese SCS imaging anatomy data and may be valuable in clinical practice.

RESUMEN: Se realizó un estudio comparativo de la morfología del seno cavernoso suboccipital (SCS) mediante resonancia magnética y muestras de yeso. El presente estudio retrospectivo analizó los datos de imágenes de venografía por resonancia magnética (RNM) craneocervical de 61 pacientes. La reconstrucción tridimensional se realizó con Mimics 19.0. Se midió: el diámetro izquierdo-derecho del SCS (d1), la distancia desde la línea mediana (d2), el diámetro superoinferior (d3), el diámetro anteroposterior (d4), la distancia desde el diámetro posterior hasta la piel (d5) y el diámetro del SCS en diferentes partes (d6-d8). En la comparación entre las imágenes RNM y las muestras de yeso, el SCS, el seno marginal, la vena condilar anterior y el plexo venoso de la arteria vertebral eran simétricos y se observaron bilateralmente, mientras que la presencia de la vena extracondilar y la vena condilar posterior presentaba tipos diferentes. La proximidad del SCS y sus vasos comunicantes y los cambios en sus vasos comunicantes se correspondieron bien con las imágenes de RNM y los especímenes moldeados. Se encontraron muchos tipos de venas condilares laterales y condilares posteriores izquierda y derecha en las muestras de yeso, que podrían dividirse en presencia bilateral de venas condilares posteriores y condilares laterales, presencia unilateral de venas condilares posteriores y presencia unilateral de venas condilares laterales. Un total de 61 casos analizados mediante imágenes MRV revelaron la presencia bilateral de venas condilares posteriores y condilares laterales (77,1 %), la presencia unilateral de venas condilares posteriores (18,0 %) y la presencia unilateral de venas condilares laterales (9,8 %) de los cuales la presencia bilateral de las venas condilar posterior y condilar lateral representó la mayor proporción. Las imágenes de RNM y las muestras de yeso del SCS mostraron su estructura morfológica y adyacencia normales, lo que proporcionó datos anatómicos de imágenes tridimensionales precisos y completos del SCS y sus estructuras vasculares comunicantes. Este estudio enriquece los datos de anatomía de imágenes de SCS chino y puede ser valioso en la práctica clínica.

Management of Chiari I Deformity in Children and Adolescents: A Report from the Consensus Taskforce of the Brazilian Society of Pediatric Neurosurgery

Much controversy remains on the current management of Chiari I deformity (CID) in children, with many clinical, surgical and ethic-legal implications. The Brazilian Society of Pediatric Neurosurgery (SBNPed, in the Portuguese acronym) has put together a panel of experts to analyze updated published data on the medical literature about this matter and come up with several recommendations for pediatric neurosurgeons and allied health professionals when dealing with CID. Their conclusions are reported herein, along with the respective scientific background.

Application of three-dimensional fast gradient echo sequence in observation of craniocervical junctional ligament / 中南大学学报(医学版)

OBJECTIVES@#To explore the value of three-dimensional fast gradient echo sequence (3D-GRE) in observation of the craniocervical junctional ligament.@*METHODS@#A total of 21 healthy volunteers underwent 3D-GRE imaging. The imaging data was imported into the post-processing workstation. The structures of the ligaments in the craniocervical junctional area were observed and evaluated by multiplanar reconstruction technique.@*RESULTS@#The features of ligaments in the craniocervical junction were shown clearly for all the 21 cases of volunteers. The scan time was 267-294 s. After the treatment with the three-dimensional reconstruction technique, the signal characteristics and the running structure of the transverse ligament, the alar ligament, the serrated ligament and the lamina could be effectively displayed.@*CONCLUSIONS@#The 3D-GRE can evaluate the three-dimensional data of craniocervical junctional ligament in a short period of time. Post-processing reconstruction technique can clearly evaluate the structure characteristics of each ligament, which can lay a foundation for further application in craniocerebral trauma patients.

Unión cráneo-cervical - anatomía normal y correlación con imágenes / Cranio Cervical Junction - Anatomy and Imaging Correlation

La solicitud de estudios de imagen en pacientes con trauma cervical es muy frecuente en la práctica diaria. Esa patología es causa relativamente frecuente de discapacidad en pacientes jóvenes junto con el trauma encéfalo craneano. En un porcentaje no despreciable de los casos, las lesiones traumáticas comprometen la unión cráneo- cervical y en esos pacientes, la morbi-mortalidad es más significativa. La transición entre el cráneo y el raquis se basa en un conjunto de estructuras óseas relacionadas por articulaciones muy móviles y estabilizadas por un grupo de ligamentos y músculos que le brindan al mismo tiempo gran solidez. Para una correcta interpretación de los estudios de imagen de uso corriente en la clínica, es fundamental un sólido conocimiento anatómico de la unión cráneo-cervical y sus componentes. Es el objetivo de esta revisión, sistematizar la anatomía de la unión cráneo-cervical con especial énfasis en sus ligamentos, analizar la fisiología de sus movimientos y el concepto de estabilidad para luego realizar una correlación con tomografía computada multi-detector y resonancia magnética.

The request of imaging techniques in patients with cervical spine trauma is very common in clinical practice. Cervical trauma is a relatively common cause of disability in young patients. In a significant percentage of cases traumatic injuries compromise the cranio-cervical junction with more important morbidity and mortality in this group of patients. The transition between the skull and the spine is based on a set of bony structures, high mobility joints, and stabilization mechanism formed by a group of ligaments and muscles. A solid anatomical knowledge of the cranio-cervical junction and its components is essential for a correct interpretation of current high resolution imaging studies. The goal of this review is highlight the anatomy of the cranio-cervical junction with special emphasis on the ligaments, analyze the biomechanics of their movements and the concept of stability. At last but not leastwe will establish a correlation with multidetector computed tomography and high-resolutionmagnetic resonance imaging.

Endoscopic Endonasal Approach to Foramen Magnum Meningioma­Technical Note and Case Example

Foramen magnum (FM) tumors represent one of the most complex cases for the neurosurgeon, due to their location in a very anatomically complex region surrounded by the brainstem and the lower cranial nerves, by bony elements of the craniocervical junction, and by the vertebrobasilar vessels. Currently, the open approach of choice is a lateral extension of the posteriormidline approach including far lateral, and extremelateral routes. However, the transoraltranspharyngeal approach remains the treatment of choice in cases of diseases affecting the craniocervical junction. For very selective cases, the endoscopic endonasal route to this region is another option.We present a case of a ventral FM meningioma treated exclusively with the endoscopic endonasal approach.

Endoscopic Endonasal Odontoidectomy: Nuances of Neurosurgical Technique / Odontoidectomia endoscópica endonasal: nuances da técnica cirúrgica

Odontoidectomy is the treatment of choice for some diseases that cause irreducible ventral compression of the brainstem. In this study, we present our series emphasizing the technical nuances of endoscopic endonasal odontoidectomy

Odontoidectomia é o tratamento de escolha para algumas doenças que cursam com compressão irredutível do tronco encefálico. Neste trabalho, apresentamos nossa série enfatizando as nuances da técnica cirúrgica da odontoidectomia por via endonasal endoscópica.

MSCTA in preoperative evaluation of complex craniocervical junction malformation / 中国医学影像技术

Objective To evaluate the necessity and clinical significance of multi-slice spiral CTA (MSCTA) in preoperative examination of complex craniocervical junction (CCJ) malformation.Methods Totally 30 patients of complex CCJ malformation were enrolled,among them 16 underwent routine CT and MRI before surgery (routine group),and the other 14 underwent MSCTA of head and neck after routine CT and MRI (CTA group).The anatomical relationship between the V3 segment of VA and the bone in CCJ was observed,and then individualized operation scheme was formulated,MSCTA data in preoperative CTA group was reconstructed.The operation time,intraoperative blood loss and complications were compared between the two groups.Results CCJ malformation and VA V3 segment variation showed obvious individual characteristics in CTA group.The average operation time was (182.86 ± 27.37)min,and the loss of intraoperative blood was (165.71 ± 42.19)ml.No obvious complications occurred,and the therapeutic effect was satisfactory during follow-up period.In routine group,the average operation time was (205.31± 29.86)min,the loss of intraoperative blood was (246.25 ± 155.22)ml.Vertebral artery injury occurred in 1 case during operation,then bleeding was controlled,and improvement was achieved during follow-up period.There was no significant difference of operation time between the two groups (t=1.878,P=0.057),while the loss of intraoperative blood in CTA group was less than that of routine group (t =2.136,P=0.042).Conclusion MSCTA is a reliable method to investigate the anatomy and variation of bone and blood vessels in CCJ.It is necessary to carry out MSCTA examination before operation in patients with complex CCJ malformation,so as to reduce the complications and avoid the risk of surgery.

Management of a Complex Basilar Invagination Case with Multiple Revision Surgeries ­ Case Report

We describe a Basilar Invagination (BI) case with craniocervical instability and many previous failure surgeries and poor wound coverage. The patient had been submitted to a large posterior fossa craniectomy (which greatly limited the availability of an adequate area for bone fixation) and showed a poor quality of the surgical wound in the posterior craniocervical region. We performed an occipito-cervical fixation, using the bone overlying the torculla as a point of cranial fixation. Craniocervical realignment was achieved by the use of distractive maneuvers with occipital rods, followed by coverage of the hardware via a pedicled longitudinal trapeze myocutaneous flap. We used local ribs removed from the region where the myocutaneous flap was harvested as autologous bone grafts for craniocervical fusion. Post-operatively, the patient was placed in a halo-vest for three months. The patient improved substantially after the procedure, recovered some muscular strength and experienced total relief of her pain. We hereby discuss the surgical strategy used for treating this complex case in details, with illustrative pictures.

Descrevemos caso de paciente com diagnóstico de invaginação basilar e instabilidade crânio cervical com múltiplas cirurgias prévias e deiscência de ferida operatória. Devido a falha de osso na escama occipital, assim como da cobertura cutânea adequada, realizamos realinhamento craniocervical, com descompressão indireta anterior, fixação occipitocervical na região da tórcula e cobertura da pele com flap miocutâneo longitudinal pediculado de trapézio. As costelas removidas da região do retalho miocutâneo foram transferidas para serem usadas como enxerto autólogo de osso para fusão craniocervical. No pós-operatório, a paciente utilizou um halo-vest por 3 meses. No presente artigo, apresentamos nuances ilustrados de manobras para realinhamento craniocervical por via posterior na invaginação basilar, bem como estratégias para otimizar a artrodese e o fechamento cutâneo.

Effect of selective indocyanine green videoangiography in the operation of craniocervical junction dural arteriovenous fistulas / 中国脑血管病杂志

Objective To investigate the effect of using selective indocyanine green videoangiography in the surgical treatment of craniocervical junction dural arteriovenous fistulas.Methods From June 2014to January 2017,the clinical data of 24 patients (26 sides) with craniocervical junction dural arteriovenous fistula treated at the Department of Neurosurgery,Xuanwu Hospital,Capital Medical University were analyzed retrospectively,including 15 with subarachnoid hemorrhage,8 with venous hypertensive myelopathy,and 1 with medullary compression symptom.The selective indocyanine green fluorescence technique was used to temporarily clip the origin of the arterilized draining vein,and the drainage vein was opened after the indocyanine green fluorescent arterial phase,and thus to determine the sites of arteriovenous fistulas.DSA examination was performed again after the operation,and the clinical efficacy was evaluated with the modified Rankin scale (mRS).Results The dural arteriovenous fistulas of 24 patients (26 sides) were separated from the fistulas during the operation.Intraoperative indocyanine green fluorescence development and postoperative DSA follow-up confirmed that the fistulas were separated.The follow-up time was 4-30 months.The mRS score in 21 patients was 0-1,the Hunt-Hess grade Ⅲ subarachnoid hemorrhage in 2 patients was mRS score 2,and mRS score in 1 patients with preoperative brainstem compression symptom was mRS score 3.Conclusion The selective indocyanine green fluorescence technique is a safe,simple,and effective technique for the treatment of dural arteriovenous fistulas at the junction of craniocervical junction.

Computed Tomography-Based Occipital Condyle Morphometry in an Indian Population to Assess the Feasibility of Condylar Screws for Occipitocervical Fusion

STUDY DESIGN: A retrospective computed tomography (CT)-based morphometric study of 82 occipital condyles in the Indian population, focusing on critical morphometric dimensions with relation to placing condylar screws. PURPOSE: This study focused on determining the feasibility of placing occipital condylar screws in an Indian population using CT anatomical morphometric data. OVERVIEW OF LITERATURE: The occipital condylar screw is a novel technique being explored as one of the options in occipitocervical stabilization. Sex and ethnic variations in anatomical structures may restrict the feasibility of this technique in some populations. To the best of our knowledge, there are no CT-based data on an Indian population that assess the feasibility of occipital condylar screws. METHODS: We measured the dimensions of 82 occipital condyles in 41 adults on coronal, sagittal, and axial reconstructed CT images. The differences were noted between the right and left sides and also between males and females. Statistical analysis was performed using the t-test, with a p-value of < 0.05 considered significant. RESULTS: Mean sagittal length and height were 17.2±1.7 mm and 9.1±1.5 mm, respectively. Mean condylar angle/screw angle was 38.0°±5.5° from midline, with mean condylar length and width of 19.6±2.6 mm and 9.5±1.0 mm, respectively. Average coronal height on the anterior and posterior hypoglossal canal was 10.8±1.4 mm and 9.0±1.4 mm, respectively. The values in females were significantly lower than those in males, except for screw angle and condylar width. Based on Lin et al.'s proposed criteria, eight of 82 condyles were not suitable for condylar screws. CONCLUSIONS: Preliminary CT morphometry data of the occipital condyle shows that condylar screws are anatomically feasible in a large portion of the Indian population. However, because a small number of population may not be suitable for this technique, meticulous study of preoperative anatomy using detailed CT data is advised.

Cervical Myelopathy Caused by Engorgement of the Epidural Venous Plexus due to Cerebrospinal Fluid Overdrainage: Case Report and Review of the Literature

This is a case report of a 33-year-old woman with cervical myelopathy caused by an enlargement of the cervical venous plexus, after she was submitted to a ventriculoperitoneal (VP) shunt that evolved to overdrainage. Magnetic Resonance Imaging (MRI) revealed an epidural venous enlargement within the spinal channel, with a 50% narrowing from C2 to C5, and spinal cord compression. A shunt revision was performed using a programmable drainage system, and a second MRI revealed the absence of the venous enlargement, resulting in cervical spinal cord decompression and remission of neurological symptoms. Compressive myelopathy consequent to the enlargement of the epidural venous plexus related to the overdrainage of the ventriculoperitoneal shunt system without typical signs of intracranial hypotension may result in misleading etiological diagnoses. Acknowledging this disorder is important to distinguish it from neoplastic processes or hematomas, for which surgical intervention may be needed.

Este é um relato de caso de uma paciente de 33 anos de idade que apresentou mielopatia cervical devido a alargamento do plexo venoso cervical, após ser submetida a uma derivação ventriculoperitoneal que evoluiu com hiperdrenagem. Exame de Ressonância Nuclear Magnética (RNM) revelou alargamento do plexo venoso epidural no canal espinhal, com estreitamento de 50% em C2 a C5, e compressão da medula espinhal. Uma revisão da derivação foi feita com um sistema de drenagem programável, e uma segunda RNM revelou ausência de ingurgitamento venoso, resultando em descompressão medular e remissão dos sintomas neurológicos. Mielopatia compressiva consequente ao alargamento do plexo venoso epidural relacionado à hiperdrenagem do sistema de derivação ventriculoperitoneal sem sinais típicos de hipotensão intracraniana pode resultar em diagnósticos incorretos. O conhecimento dessa patologia é importante para distingui-la de processos neoplásicos ou hematomas, nos quais intervenções cirúrgicas podem ser necessárias.

Biomechanical of lateral atlantoaxial articulation in craniocervical junction malformation:afinite element analysis / 重庆医学

Objective To analyze the biomechanical changes of lateral atlantoaxial articulation by means of three‐dimensional fnite element models of craniocervical junction malformation(CJVM) .Methods CT scan images of 1 patients with CJVM were ob‐tained .The analytical model was constructed by advanced three‐dimension modeling and finite element softwares .A comparison of range of motion difference between the deformity model and normal model ,referring to the experience of clinical observation ,was used to verify the validity of the model .Applying respectively the same loads and boundary conditions on finite element model .The effectiveness was verified by contrastive analysis of the variation in lateral atlantoaxial joint stresses .Results The finite CJVM ele‐ment model with high geometric accuracyand reliable parameter had built .Compared to the results of cadaver test and finite element model based in normal cranio‐cervical junction ,the segment mobility coincides with the actual clinical performance in patients .The stress distribution the lateral junction between atlas and axis of can be reasonably explained the deformation of lateral atlanto‐axial joint structure and its important role in remaining stable between atlantoaxial vertebraeunder different physiological conditions .Con‐clusion The structure of lateral atlantoaxial joint changes in patients of CJVM ,the biomechanical stability for preoperative diagno‐sis and intraoperative treatment operation has a certain value .

Idiopathic Hypertrophic Pachymeningitis in the Craniocervical Junction

Idiopathic hypertrophic pachymeningitis (IHP) is a rare disease, and it is characterized by chronic progressive inflammatory fibrosis and thickening of the dura mater with resultant compression of the spinal cord or neural structure without any identifiable cause. It can occur in the intracranial or spinal dura mater alone or as a craniospinal form. The spinal form is rarer than the cranial form and the craniospinal form is extremely rare. We report a rare case of IHP in the craniocervical junction involving both the cranial and spinal dura mater and discuss the diagnosis and management of the disease.

Diagnóstico clínico e radiográfico de luxação traumática da articulação atlanto-occipital em dois cães / Clinical and radiographic diagnosis of traumatic dislocation of the atlanto-occipital joint in two dogs

A luxação da articulação atlanto-occipital é considerada uma afecção incomum no homem e nos animais. Radiografias laterais são recomendadas para o diagnóstico. No entanto, estão sujeitas a erros relacionados ao ângulo de radiação, ao alvo da imagem, à distância e à sobreposição óssea. Objetivou-se neste relato descrever os achados clínicos e radiográficos de dois cães com luxação traumática da articulação atlanto-occipital que apresentavam tetraparesia, dor cervical cranial, incapacidade de elevar a cabeça e déficits de nervos cranianos. No primeiro animal, observaram-se deslocamento craniodorsal do processo articular do atlas em relação a um dos côndilos do occipital, ausência de sobreposição dos forames vertebrais laterais e sobreposição do côndilo do occipital ao processo articular do atlas, no lado direito, caracterizando uma luxação unilateral. No segundo animal, observou-se deslocamento craniodorsal dos processos articulares do atlas em relação aos côndilos do occipital, com sobreposição dos forames vertebrais laterais e ausência de visibilização dos côndilos do occipital em virtude da projeção cranial dos processos articulares do atlas em direção ao crânio, caracterizando luxação bilateral. Conclui-se que o exame radiográfico simples, nas projeções laterolateral e ventrodorsal, apesar da dificuldade de ser interpretado, é eficiente para confirmar o diagnóstico da luxação atlanto-occipital traumática, tanto a simétrica quanto a assimétrica.

Atlanto-occipital luxation is considered rare in both humans and animals. Lateral radiographs are recommended for diagnosis, however, errors may occur related to the angle of radiation, image target, distance and overlapping of bone. Our objective is to report the clinical and radiographic findings in two dogs with traumatic atlanto-occipital luxation, which had tetraparesis, cranial neck pain, and inability to raise the head and cranial nerve deficits. The first animal had a cranio-dorsal dislocation of the articular process of the atlas in relation to one of the occipital condoles, with no overlapping of the transverse foramens or overlapping of the occipital condile in relation to the articular process of the atlas, on the right side, which characterizes a unilateral luxation. The second animal presented with a cranio-caudal dislocation of the articular processes of the atlas regarding the occipital condoles, with overlapping of the transverse foramens and inability to visualize the occipital condoles due to the cranial advancement of the articular processes of the atlas towards the skull, which characterizes a bilateral luxation. We conclude that a simple radiographic exam, in lateral and ventrodorsal projections, though difficult to interpret, is efficient in confirming a diagnosis of traumatic atlanto-occipital luxation, both symmetric and asymmetric.

Surgical Treatment of Craniovertebral Junction Instability : Clinical Outcomes and Effectiveness in Personal Experience

OBJECTIVE: Craniovertebral junction (CVJ) consists of the occipital bone that surrounds the foramen magnum, the atlas and the axis vertebrae. The mortality and morbidity is high for irreducible CVJ lesion with cervico-medullary compression. In a clinical retrospective study, the authors reviewed clinical and radiographic results of occipitocervical fusion using a various methods in 32 patients with CVJ instability. METHODS: Thirty-two CVJ lesions (18 male and 14 female) were treated in our department for 12 years. Instability resulted from trauma (14 cases), rheumatoid arthritis (8 cases), assimilation of atlas (4 cases), tumor (2 cases), basilar invagination (2 cases) and miscellaneous (2 cases). Thirty-two patients were internally fixed with 7 anterior and posterior decompression with occipitocervical fusion, 15 posterior decompression and occipitocervical fusion with wire-rod, 5 C1-2 transarticular screw fixation, and 5 C1 lateral mass-C2 transpedicular screw. Outcome (mean follow-up period, 38 months) was based on clinical and radiographic review. The clinical outcome was assessed by Japanese Orthopedic Association (JOA) score. RESULTS: Nine neurologically intact patients remained same after surgery. Among 23 patients with cervical myelopathy, clinical improvement was noted in 18 cases (78.3%). One patient died 2 months after the surgery because of pneumonia and sepsis. Fusion was achieved in 27 patients (93%) at last follow-up. No patient developed evidence of new, recurrent, or progressive instability. CONCLUSION: The authors conclude that early occipitocervical fusion to be recommended in case of reducible CVJ lesion and the appropriate decompression and occipitocervical fusion are recommended in case of irreducible craniovertebral junction lesion.

Hematoma epidural pós-traumático na junção crânio-cervical: relato de caso e revisão de literatura / Post-traumatic epidural hematoma in the craniocervical junction: case report and review of the literature

Os autores relatam um caso raro de hematoma epidural pós-traumático na região da junção crâniocervical.Paciente de 63 anos, após grave acidente automobilístico, evoluiu com dor cervical intensa,refratária ao tratamento clínico. A ressonância magnética demonstrou um hematoma epidural desde ajunção crânio-cervical até C1-C2, de localização póstero-lateral direita, sem alterações de partes ósseas.Optado pelo tratamento cirúrgico imediato, foi realizada laminectomia com retirada do hematoma. Houvedesaparecimento da dor e resolução completa do hematoma, comprovado pela ressonância magnética.É feita revisão da literatura sobre o tema.

The authors report a rare case of post-traumatic epidural hematoma in the craniocervical junction ina 63 y.o. male patient, following a car accident. He presented with intense cervical pain refractory tothe clinical treatment. The magnetic resonance imaging demonstrated an epidural hematoma fromthe craniocervical junction down to C1-C2 level, on the right posterior-lateral region, without any bonealterations. An immediate laminectomy for drainage of the hematoma was carried through. The patientpresented alleviation of the pain and complete resolution of the hematoma, as proven by the magneticresonance imaging. Revision of literature on the subject is made.

Helical CT diagnosis of maxillofacial fractures associated with craniocervical junction injury / 中华创伤杂志

Objective To explore imaging manifestations and diagnostic value of helical CT in maxillofacial fractures associated with craniocervical junction injury. Methods Helical CT findings of ten cases with maxillofacial fractures involving the craniocervical junction injury were retrospectively analyzed and compared with other imaging techniques. Results There were five cases with both fractures of the maxilla and mandible combined with zygomatic arch fractures, three with mandible fractures combined with dislocation of temporomandibular joint and three with mandible fractures combined with slight and moderate craniocerebral injuries. The combined craniocervical junction injuries included atlantoaxial rotary dislocation in six cases, occipital condyle avulsion fracture in two and occipitocervical subluxation in two. Conclusions Maxillofacial fractures combined with the occipitocervical junction injuries are usually ligament injuries, with radiologic characteristics of avulsion fracture, occipitocervical subluxation and atlantoaxial rotary dislocation. Helical CT is a satisfactory mode for diagnosis of such fractures. More attention should be paid to mark of anatomical relation of craniocervical junction to avoid missed diagnosis.

Neurovascular Morphometric Aspect in the Region of Cranio-Cervical Junction

OBJECTIVE: During the trans-condylar or trans-jugular approach for the lesion of cranio-cervical junction(CCJ), its necessary to identify the accurate locations of vertebral artery(VA), internal jugular vein(IJV) and its related lower cranial nerves. These neurovascular structures can also be damaged during the operation for vascular tumor or traumatic aneurysm around extra-jugular foramen, because of their changed locations. To reduce the neurovascular injury at the operation for CCJ, morphometric relationship of its surrounding neurovascular structures based on the tip of the transverse process of atlas(C1 TP), were studied. MATERIALS AND METHODS: Using 10 adult formalin fixed cadavers, tip of mastoid process(MT) and TPs of atlas and axis were exposed bilaterally after removal of occipital and posterior neck muscles. Using standard caliper, the distances were measured from the C1 TP to the following structures: 1) exit point of VA from C1 transverse foramen, 2) branching point of muscular artery from VA, 3) entry point of VA into posterior atlanto-occipital membrane(AOM), 4) branching point of C-1 nerve. In addition, the distances were measured from the mid-portion of the posterior arch of atlas to the entry point of the VA into AOM and to the exit point of the VA from C1 transverse foramen. After removal of the ventrolateral neck muscles, neurovascular structures were exposed in the extra-jugular foraminal region. Distances were then measured from the C1 TP to the following structures: 1) just extra-jugular foraminal IJV and lower cranial nerves, 2) MT and branching point of facial nerve in parotid gland. In addition, distance between MT and branching point of facial nerve was measured. RESULTS: The VA was located at the mean distance of 12mm(range, 10.5-14mm) from the C1 transverse foramen and entered into the AOM at the mean distance of 24mm(range, 22.8-24.4mm) from the C1 TP. The mean distance from the mid portion of the C1 posterior arch was 20.6mm(range, 19.1-22.3mm) to the entry point of the VA into AOM and 38.4mm(range, 34-42.4mm) to the exit point of the VA from C1 transverse foramen. Muscular artery branched away from the posterior aspect of the transverse portion of VA below the occipital condyle at the mean distance of 22.3mm(range, 15.3-27.5mm) from the C1 TP. The C-1 nerve was identified in all specimens and ran downward through the ventroinferior surface of the transverse segment of VA and branched at the mean distance of 20mm(range, 17.7-20.3mm) from the C1 TP. The IJV was located at the mean distance of 6.7mm(range, 1-13.4mm) ventromedially from the lateral surface of the C1 TP. The XI cranial nerve ran downward on the lateral surface of the IJV at the mean distance of 5mm(range, 3-7.5mm) from the C1 TP. Both IX and X cranial nerves were located in the soft tissue between the medial aspect of the internal carotid artery(ICA) and the medial aspect of the IJV at the mean distance of 15.3mm(range, 13-24mm) and 13.7mm(range, 11-15.4mm) from the C1 TP, respectively. The IX cranial nerve ran downward ventroinferiorly crossing the lateral aspect of the ICA. The X cranial nerve ran downward posteroinferior to the IX cranial nerve and descended posterior to the ICA. The XII cranial nerve was located between the posteroinferior aspect of the IX cranial nerve and the posterior aspect of the ICA at the mean distance of 13.3mm(range, 9-15mm) ventromedially from the C1 TP. The distance between MT and C1 TP was 17.4mm(range, 12.5-23.9mm). The VII cranial nerve branched at the mean distance of 10.2mm(range, 6.8-15.3mm) ventromedially from the MT and at the mean distance of 17.3mm(range, 13-21mm) anterosuperiorly from the C1 TP. CONCLUSION: This study facilitates an understanding of the microsurgical anatomy of CCJ and may help to reduce the neurovascular injury at the surgery around CCJ.